This year much has been written in both the medical
and the popular press about the changes in the National
Health Service (NHS) since its launch 60 years ago.
While the majority of articles are complimentary,
praising the NHS and reminding us of how much
the NHS is admired by the rest of the world, many
authors do point to the challenges of rising costs, an
ageing population and the changing public expectations
that the NHS now faces. Some of these articles
describe the changes in the organisation of the NHS
over the last 60 years, but little has been said about the
implications of these changes for patients. This paper
looks at some of the implications for patients of the
way that general practice is now organised.

At the beginning of the NHS, patients registered
with a general practitioner (GP). Patients were taken
on board for life and the value of the ‘longevity’ of the
doctor–patient relationship was described as of prime
importance for the doctor, who could monitor the
illness experience of patients for the length of their
lives,[1] as well as for the impact on succeeding generations.
This continuity of care was also much appreciated
by many patients and their families. The GP was
a well-known, respected and trusted member of the
community whom patients not only turned to with
their medical problems, but felt able to discuss more
personal and psychological problems.[2] Surgeries, though
very often inmodest premises, were conveniently located
in town centres easily accessible on foot or by public
transport. Most family doctors were in small partnerships
or single-handed. They usually had both appointments
and open-access surgeries, paid home visits and
looked after their own patients out of hours.[3]

Perhaps the most significant difference for patients
after the beginning of the NHS was that direct financial
transactions were removed fromthe consultation.
For many patients this meant that they were able to
visit the GP without the fear of going without necessities
or even food. Dignity for patients and doctors
alike was given to the consultation.[2]

Over the last 60 years there have been considerable
changes in the way general practice is organised. There
are fewer smaller practices, with more GPs working in bigger partnerships and operating fromhealth centres
that are often purpose built, and providing more facilities.
[4] However, these centres are not always situated in
the most convenient locations for the centres of population,
are not always serviced by public transport, and
thus requiremuch greater use of private transport. For
some older patients who do not drive, getting to the
GP surgery has become problematic. This is acknowledged
in a recent quote by Professor Martin Roland in
discussing polyclinics: ‘... there is quite good evidence
that patients don’t like big practices and satisfaction is
higher in smaller practices. Plus if practices are concentrated
in large facilities access for patients is reduced.
Patients have further to go and that is a particular
problem for the old and disabled’.[5]

Throughout the last 60 years, ease of access to one’s
GP has fluctuated. In the first years of the NHS, access
was good even though patients may have had to wait
for quite some time in an open-access clinic, essential
whenfewer patients had telephones. Governmentfigures
now tell us that the majority of patients are being
offered a non-urgent appointment to see a doctorwithin
48 hours, although it may be longer to see the doctor of
one’s choice. Nevertheless, there do seem to be difficulties
for some patients wishing to see their ‘own’
doctor quickly for a problem that the patient perceives
to be relatively urgent. Such patients value the continuity
of care given when they see the doctor who knows
them and their health problems.[6] Wider use of telephone
consultation and email communication, known
to be helpful to both patients and doctors, could be
encouraged. There is an additional problem relating
now to the lack of flexibility and range of times when
patients can consult their GP. Where surgery hours in
many GP surgeries are between 8.30am and 5pm in a
commuting town, and when there are no surgeries on
a Saturday morning, many patients may have to take
time off work for even a routine GP appointment.
Furthermore, tasks, for example taking a blood sample,
previously done ‘on the spot’ and often by the GP, in
many practices now require another visit to a specialist
clinic in a community hospital. Recent government
recommendations for GPs to extend their opening times should help a little, particularly if these hours are
sensitive to the needs of the local patient population. It
is of interest to note that the most frequent ‘complaints’
to the patient organisation, Patient Concern,
are now about GP services, in particular access to the
GP of the patient’s choice and continuity of care
(personal communication, Joyce Robbins Co Director,
Patient Concern).

It is likely that continuity of care provided by a
doctor known to the patient has always been valued by
patients. Recent patient surveys continue to show that
patients still want and value continuity of care.[7] However,
changes in the way that primary care is organised
and delivered since the formation of the NHS have
also created challenges for continuity of care. These
changes include GPs relinquishing responsibility for
out-of-hours (defined as between 18.30 and 08.00,
weekends and bank holidays) services that may make
continuity of care problematic for the terminally ill,
the frail elderly and those with complex healthcare
needs.Arecent study by Richards et al explored the use
of out-of-hours services following the implementation
of the new general medical services (GMS) contract
for patients with cancer.[8] The authors concluded that
out-of-hours providers face substantial difficulties in
identifying patients with complex needs, in particular
those with palliative care needs and suggest that ‘it is
vital that the software evolves to allow audit and
possible monitoring of vulnerable groups if around
the clock effective interagency communication is to be
realised’. From the patient perspective, common sense
would suggest that practices alert the out-of-hours
service about frail and terminally ill patients who may
try to contact them. This can help with continuity of
care and ease the triage process that can be time
consuming and often distressing for agitated relatives
or carers.

The removal of direct payment to the doctor at the
beginning of the NHS was arguably the most significant
change for patients and doctors. Doctors and
patients did not need to be concerned about how fees
would be paid. Doctors were able to recommend treatments
without concern about whether the patient
could pay, and patients could receive emergency, elective
and preventive interventions without fear of how to
pay. Since the beginning of the NHS, concerns have
continued to be raised about escalating costs and
about whether resources were being used wisely. From
1952 to 2007, reports from the King’s Fund have stated
that more resources will be needed unless productivity
increases.[9] This is not simply a feature of a state-funded
system but can be found in health systems round the
world, regardless of the system of Funding. Over the
last 60 years, each successive government has introduced
measures in attempts to control increasing costs and
to make the service more accountable. This was inevitable
and correct once the state took responsibility for the Funding of the NHS. Accountability for how
resources are used in the NHS is not only to the
government but should also be to the public. The
present government is making considerable efforts to
involve the public more in decision-making processes
at both national and local level.[10]Unfortunately, because
the public are ignorant about the actual costs of
different services and treatment, there is considerable
suspicion when changes are introduced to monitor
costs and standards and rationalise services that could
benefit the whole population.

A consequence of some of these changes is that cost
has gradually crept back into the consultation and is
very often related to the prescribing of drugs. A recent
very public example is the ban preventing patients
making ‘top up’ payments for drugs. The fear is that
ending the ban would open the door to a two-tier
health system with the state offering a minimum
service and the rest available to those who could afford
it, a situation breaking with the founding principles of
the NHS. Another example is the availability of the
drug ranibizumab (Lucentis) for ‘wet’ age-relatedmacular
degeneration (ARMD).[11] In some primary care
trusts (PCTs) Lucentis became available in 2007 for
patients only when the second eye was affected. More
recently, other PCTs are paying for treatment where
either eye is affected.[12] How difficult is it for a patient
who learns that a treatment that could be beneficial
and is available in a different geographical area is not
available to them and that their GP is powerless to help
because the PCT will not authorise payment of the
drug? It is very possible that such a situation may
profoundly affect the relationship between the patient
and their GP and could reduce the respect for the GP.

The Quality and Outcomes Framework (QOF)
voluntary system to remunerate general practices for
providing good-quality health care and to help fund
work to further improve the quality of care delivered
was introduced as part of the GMS 2004 contract. It
can be argued that the QOF has brought cost back into
the consultation. However, unlike the situation before
the start of the NHS when the patient paid the doctor
for services, in the QOF there is no direct payment
between doctor and patient but it is necessary for
the doctor to see the patient to acquire some of the
information needed for the QOF. It is unlikely that the
majority of patients know the significance of the QOF
in generating income for the practice. Furthermore,
there is anecdotal evidence that some patients are questioning
why the doctor asks questions that do not
appear related to the reason for the patient’s visit and
describe this as ‘feeling that they are boxes to be ticked’. It
is more likely that the trust and respect of patients will
be gained when there is a more transparent approach
to informing the public how GPs are paid.

The way that both general practice services and the
widerNHS are now organised is complex and unlikely to be understood by most patients. This paper has
highlighted some of the implications for patients of
administrative changes over the last 60 years in the way
that general practice is delivered. It has been necessary
to be selective, and some important aspects have been
omitted. Moreover, the reasons for some of these
changes, however necessary, have not been discussed.
The aim of the paper is simply to identify and highlight
the effect on patients of specific changes.

Peer Review

Commissioned, based on an idea fromthe author; not
externally Peer Reviewed.

References

Blythe M. Almost a Legend: John Fry leading reformer of general practice. London: Royal Society of Medicine, 2007.

Forsyth G. Doctors and State Medicine: a study of the British health service. London: Pitman Medical, 1973.

Royal Commission on the National Health Service. The Merrison Report. London: HMSO, 1979.

Wilkie P. The value of general practice to the public. In: Lakhani M (ed) A Celebration of General Practice. Oxford: Radcliffe Publishing, 2003.

Crying out for flexibility. Health Service Journal Supplement 2008; 5–7.